Why the physician shortage in the VA is a sign of things to come

The metallic mix of freshly spilled blood and sterile instruments engulfed his nostrils as he shifted uncomfortably in the cracked, worn, brown leather chair where so many others had sat before him. He tried not to sweat as the faceless, gray clinician coaxed the long needle deeper into his fleshy neck and watched as a rogue drop of crimson escaped and marred the otherwise pristine tile floor beneath him. He could just make out the sound of laughter, muffled by the aging, wooden door that separated him from a somber new beginning.

My brother was 29 and a chief engineering officer in the U.S. Navy when he was first diagnosed with cancer. That biopsy marked the beginning of a long battle he’s still fighting today. His treatments required several rounds of surgery and radiation, so he retired from active duty and immediately applied for insurance with the VA. Three years, dozens of phone calls and personal office visits later, his status is still listed as “pending.” During that time, his only options have been to pay for 100 percent of his care out of pocket, purchase independent private insurance or forego much-needed therapy altogether.

His experiences made me wonder what was happening to other veterans that didn’t have the same financial freedom he did. This past summer, the Huffington Post provided me with the chilling answer when they published the VA’s 2015 Analysis of Death Services Report. This leaked document states that, “nearly 1/3 of the 847,000 vets with pending applications for VA health care have already died.” Let me rephrase that. Approximately 240,000 people who dedicated their lives to defending this country have died waiting for the health insurance they were promised by our government.

Last year, several news sources also confirmed that even vets with insurance were waiting up to 20 months to schedule appointments with primary care physicians — many of them dying before they could receive treatment.VA Press Secretary Victoria Dillon assured readers that, “the agency has made strides on that front, doubling the number of its appointments from 3.5 million to 7 million since last year.” Yet during this time, they hired only 1000 new physicians — an increase of 4.3 percent for a 100 percent increase in scheduled visits.

The VA is the largest government-run health care provider in the U.S., and it’s not doing a very good job because it fails to address simple arithmetic: increases in patient populations must be met with equivalent increases in qualified staff — otherwise, longer wait times, shorter office visits and decreasing quality care are sure to follow. While this may seem like common sense, we’re headed down the exact same path on a national scale.

Americans are getting older and sicker, requiring more complex care. At the same time, the ACA is expanding coverage to millions of previously uninsured citizens. While I fully support health insurance coverage for all Americans, the VA has shown us that simply cramming more patients into an already over-saturated system does little to help. We need to increase the number of practicing clinicians while also learning to use the ones we have more efficiently.

The vast majority of physicians went to medical school for one reason: to care for patients. Unfortunately, we spend greater than 30 percent of our time on required tasks that have nothing to do with direct patient care — filling out charts, obtaining insurance approvals, faxing paperwork and ordering prescriptions. We are subjected to more and more Medicare regulations while spending inordinate amounts of time printing out handouts that are largely thrown away.

None of these tasks have been shown to improve quality. They have, however, significantly altered the practice of medicine as physicians now spend an average of only 8 minutes involved in direct patient care. It is simply not possible to provide adequate care with so little time. Recent research has shown that these unrealistic demands have been tied to higher rates of physician burnout, retirement and suicide.

We can begin to address these issues by eliminating extraneous paperwork and hiring medical scribes and technicians to assist with the necessary tasks. Scribes generally have a medical background and are a reliable and cost-effective alternative to nurses and physicians when it comes to paperwork. This strategy has already implemented in busy emergency rooms across the country. Hiring more scribes would create 1000s of jobs a year and cut down on the amount of time clinicians spend staring at a computer, giving them more time to spend with you, their patients.

Unless we start to think seriously about the current expectations placed on physicians, we’re heading for a system that looks painfully similar to the current VA. If that’s the case, ask yourself if waiting 20 months to see a doctor for less than 10 minutes is the type of care you’d want for your brother, your parents or yourself. Personally, I’d prefer to work in a system where 1/3 of patients don’t find themselves literally dying for care.

Sarah Mongiello Bernstein is a pediatrics resident and can be reached on Twitter @sbernsteinmd.

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Why the physician shortage in the VA is a sign of things to come 23 comments

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Thomas D Guastavino

34 years ago I spent my last two months (May, June) of internship on a VA Internal Medicine rotation. We became extremely busy with a ton of admissions with very minor complaints because the word came down to “admit everyone”. Reason? The VA was paid on the basis of an audit of filled beds.
The VA has been an inefficient dinosaur for a very long time and needs to be eliminated, replaced with simply underwriting the vets insurance. They would get much better, deserved care.

gleannfia

Sure, then vets can get the same crappy 10-15 min appointments that the rest of us get in corporate medicine. With all due respect, Dr. , things have changed a lot in the past 34 years in the VA. I work in the Minneapolis VA. We get people in far faster than I myself get in the private sector.

Thomas D Guastavino

Interesting. Perhaps the rest of the VA system should copy what you are doing in Minneapolis. Obviously you are doing something they are not.

patricia kelly

Yes, there are many shortages in the VA—no argument. But I am puzzled why he was not medically retired from the Navy and thus fully eligible for TriCare—–he should have been. The VA guarantees care for service-connected disabilities but not general medical care for all vets, but the military does guarantee insurance for all illnesses acquired during the time of service if they cause the need to retire.

gleannfia

Yes, Patricia, I was scratching my head over this one as well.

Dr. Drake Ramoray

This was a good piece…… Until the scribes part. Remove regulations, red tape, administrators and bureaucrats and scribes would be unnecessary.

Medicine in this country is broken as long as we provide more administrative types to do work foisted on doctors by other administrative types. It’s a never ending vicious cycle.

gleannfia

I agree. My theory is that there is a whole legion of middle management and administrative types that have to justify their salaries. They are really sucking off the nurses, physicians, and allied health professionals that actually provide patient care. How about the people who do ICD and the “education” departments in most institutions.

Sarah Bernstein

Thanks for the feedback. In hindsight, I don’t disagree with you! The portion regarding scribes was an effort to attempt to address the necessary paperwork (as I don’t think it’s entirely inescapable). That being said, MUCH of the requirements are superfluous, and I think everyone would benefit from it being scaled down significantly. Maybe I can talk you into editing my next post? 🙂

buzzkillerjsmith

Even if we brought admin tasks to zero, there would still be a wicked shortage of PCPs. Decreasing these tasks is a great idea but won’t get us to medical nirvana. Fact is that fam med and gen int med are crap jobs compared with other fields. It has been that way for a least the 26 years I’ve been in the game and it is getting worse as pts get older and sicker.

Multiply the salary by 1.5 or 1.66 and we got something maybe to talk about a little. Otherwise we’re urinating windward.

Joe

I completely agree, my extensive dealings with the VA as a doc have been negative. It’s time to give our vets access to Medicare/Medicaid and close this dysfunctional system down.

buzzkillerjsmith

I have a buddy whose dad did a lot of work for Caltrans (California’s road maintenance folks, a governmental entity) back in the day. Apparently people who not satisfied with it so a study was commissioned 25 years ago that recommended killing Caltrans and starting all over. It’s still around.

Dr. Drake Ramoray

“The nearest thing to eternal life we will ever see on this earth is a government program.”

– Ronald Reagan

LeoHolmMD

Well said. The way our veterans are treated is a disgrace to this country.

gleannfia

Could not disagree more. Most of us at the VA are hardworking. Yeah, there are the slackers, but I found those in the private sector as well. I think we all should focus on getting rid of the parasites.

gleannfia

Interesting how so many who post here think corporate medicine is so pristine. As both a patient and a provider, I can tell you that is unequivocally untrue.

gleannfia

The funny thing is, every single day, my vets are telling me how happy they are with the care they receive at the VA. getting more and more physicians fleeing from the private, They don’t understand all of the negative publicity. Sadly, though, there ARE differences between VAs. The ones affiliated with medical schools tend to be better. On another note, we are finding more and more physicians fleeing from the profit-driven community systems. The docs I work with all seem generally happy.

Joe

Maybe you should spend a few days in my clinic. You will get a much different view from the vets I see.

Michael Mongiello

The doctors are usually happy and so are the patients whom do not have serious issues or those whom are being seen at all. I will write my response to some of these questions below shortly.

Michael Mongiello

Thank all of you for your interest and comments regarding this highly volatile topic of discussion. I am Michael, and this report is about me, and due to rhetoric and word constraints, the author and I felt some of the finer details were not necessary for the intent to be understood. Many of you who have commented have either worked or have been treated at the VA. Every person I have ever come into contact with at the VA, from the doctor to janitor, has been amazing. The issue is not with the people who work at the VA, it is with the administration and those that run the facility at the higher up offices.

I will attempt to answer a few questions that you may have, and a few that have been voiced in the comments above. In 2012, after 12 years of active duty military service, I was diagnosed with cancer. After I was treated by a facility apart from the military both the VA and the Navy cleared me “medically fit to continue work.” The VA was involved at this time because I was close to the end of my active duty service obligation and I was not able to extend until medically clear. This decision came in 2013, almost a full year after the treatment, and during a time where the following physician had found evidence of metastatic disease. I filed paperwork with the Navy and VA stating that I was not fully cured with the intent to remain under treatment on active duty. The metastasis was clearly present as evident by my blood numbers, but the Navy denied this request because no proof of active cancer in the form of a surgical biopsy had been done by this time. Because of my approaching end of service date, a decision was required to either start my career over (the disease disqualified me from my current job operating the Navy’s reactors but did not disqualify me for some other Navy jobs), or receive an honorable discharge and seek treatment outside of the military and continue a career in the same field. Because the Navy did not recognize that the disease was still rampant in my body, they would not allow me to stay with my current doctors and intended to move me across the country onto a ship without appropriate care. This was an unacceptable option to me, and my health came first.

After I was discharged, the VA took an additional 3 years to rule on my case as to whether or not this was “service related” so that I could receive free care through the VA. Knowing that once the VA ruled in my favor, I opted to continue treatment with the VA and paying out of pocket for services that were not covered as of yet. I did this because the VA would back pay all expenses once the case was ruled in my favor. After about 6 months of treatment at the VA, the fellow entered the room with a few other doctors to tell me that my cancer had indeed spread to my lymph system and required intensive surgery and radiation. The fellow admitted that I needed a specialist and that the VA did not have such a specialist on staff. She advised me that she would write a letter to the Chief of Surgery asking for me to be released for VA payment to outside facilities for treatment because the VA could not provide appropriate care.

At my next appointment, the fellow told me that her request had been denied in writing, denied in person, and denied for a third time after an additional try by the Chief of Surgery due to “wanting to keep money in the VA system.” She explained that the VA was going to transfer my care to a VA facility over 200 miles away that had the same type of surgeons and no specialist. She openly explained to me that the VA couldn’t treat my disease appropriately. She told me that I needed outside care and she had done everything she could to help me get it, but her hands were tied. And she told me that if I were her or her children, she would seek treatment elsewhere. My wait to see the doctor was more than 3 months long, and this was unacceptable with spreading disease.

Because I should have been able to receive medical treatment through the VA, but the case had not been ruled on yet, the government would not allow me to purchase health insurance through the affordable healthcare act. Therefore, I started my treatment as a cash patient because continued treatment at the VA, although they would pay me back, was not an option.

As I said at the beginning, after waiting 6 months for care, as I had done a few times, and navigated the red tape of the VA healthcare system, the interactions of the staff were always pleasant.

I hope this helps to answer some questions,

Mike

Mike Renell

1. VA is not insurance …
2. VA doctors DO NOT check for insurance
3. THE VA has vastly improved over the last 34 years
4. Non Clinical nurses are over paid at the VA – trim some of that fat
5. THE VA EDUCATES MORE MD, DO,OD Pharm, Nurses than any where else in the NAtion
6. Your brother received a service rating… you have no idea how this works

Sarah Bernstein

Hi Mike, Thank you for taking the time to read my article and respond. Please see Michael Mongiello’s lengthy post above, as I think it addresses several of your concerns. As he mentions, many of the specific details regarding his care/the process were not addressed in the body of the article due space limitations and relevance, but hopefully will help answer some of your questions.

While I agree that the VA is the largest educator of physicians in the country and has improved vastly over the last 34 years, I don’t think that either of these things (quantity of providers/improvement in care) necessarily translates into high-quality, reliable care. I can only speak from our personal experience, but the articles in Huff Post/NY Times indicate that he is not by any means the only person to experience long wait times/inadequate treatment.

Michael Mongiello

It is going the way of European medicine I think. There will be two classes of healthcare; the rich who can afford the expensive doctors that make house calls and can pay out of pocket without the need for insurance, and the Medicaid/Medicare class…nothing in between.

Michael Mongiello

The VA is like almost every other government run system. It’s was great in the beginning because the intention and reason it was started was pure, but through the years has become so corrupt that the few benefit from the misfortune of others. Take it from experience of the Command Chief (me/military) of an entire base who has decision authority of everyone on that base, and a government employee who is in charge of the military base housing. Although this employee was openly racist, was a detriment to the base housing project putting military families at risk and used government vehicles and navy military members to facilitate her personal house move (if you don’t know, this is VERY bad). With all of this, she still could not be fired from her job. She could only be transferred to another facility. To facilitate this movement, the was promoted by the people in charge of her so that she no longer qualified for this job. We (the military executive suite) contacted her management to discuss this action. His response was that it is almost impossible to fire a government employee, the best thing that can be done is move the employee somewhere else.

So, in the end, government employees who do not perform well are promoted, paid more and moved from one headache to another. After 20 years, some of these people are paid over $100,000 to sit and answer a phone all day and not file paperwork, and you can’t do anything about it. There are plenty of poor/homeless people I would rather see in these positions who appreciate working. They would receive a reasonable wage and would be grateful for the opportunity.

Big picture, what the author is trying to foreshadow with this story, is that the VA is a preview of things to come with the government taking over the general healthcare system. Everyone’s individual opinions and personal experiences may be different but the common thread is that, although the shift in healthcare is a good intention, no one can deny that the VA is far from a model that we want the rest of the nation to follow. As Dr. Bernstein alluded to, there are countless examples of why this is true.